2008 25 Exophiala dermatitidis 1 19 3 29 20 1 9 53 X CT 35 black yeast 27 Exophiala dermatitidis miconazole (MCZ) flucytosine (5- FC) itraconazole (ITCZ) E. dermatitidis immunocomprised patient Key words: Exophiala dermatitidis, dematiaceous fungi, pulmonary chromomycosis Exophiala dermatitidis 1), 2) 3) I. 53 1999 10 ( 830 0011) 67 TEL & FAX: 0942 31 7760 E-mail: tanamachi chiyoko@kurumeu.ac.jp 1999 10 tosufloxacin (TFLX) 300 mg/day clarithromycin (CAM) 400 mg/day 1999 11 37 erythromycin (EM) 600 mg/day 2 moist rales 2000 7 EM cefpodoxim (CPDX) 2002 12 (1 3)-b-9-4) 40.0 pg/ml 11 pg/ml 2003 1 itraconazole (ITCZ) 300 mg/day EM 400 mg/day X Vol. 18 No. 1 2008. 25
26 Fig. 1. Chest X-ray photo of the patient a) Shadow in the lower right field on admission (red arrow). b) Improved shadow after treatment. Fig. 2. Chest CT scan a) Reticular-granular shadow and exteded bronchi wall are recognized in the right middle lobe. b) Same findings are recognized in the right lower lobe. CT 2003 7 14 156 cm 50 kg 36.8 14/ 72/ 116/ 70 mmhg X (Fig. 1-a) CT X (Fig. 2) Table 1 CRP (1 3)-b-9- (Fig. 3) II. (1 ) 20 YBC 30 24 48 26 Vol. 18 No. 1 2008.
Exophiala dermatitidis 27 Table 1. Laboratory data on admission Complete blood count WBC 11.7 10 3 /ml Acid-fast stain Negative Bas 0.2 PCR Eo 0.9 M. tuberculosis Negative Neu 79.3 M. avium complex Negative Ly 13.7 Culture on Ogawa Negative Mo 5.9 Aspergillus antigen Negative RBC 4.51 10 6 /ml Anti-Aspergillus Ab Negative Hb 13.4 g/dl (ELISA) Ht 42 Cryptococcus antigen Negative Plt 20.1 10 4 /ml b-9-glucan 27.3 pg/ml Laboratory data TP 7.25 g/dl GOT 13 IU/L GPT 7 IU/L LDH 166 IU/L ALP 276 IU/L BUN 9.4 mg/dl Cr 0.64 mg/dl CRP 2.37 mg/dl Fig. 3. Many yeasts in bronchial washings of the patient (Grocott stain 400) API 20C AUX 30 24 48 72 27 (Slide Culture) 5) 27 2 3 Fig. 4. Giant colony cultured on 30th day Vol. 18 No. 1 2008. 27
28 Table 2. Susceptibility of antifungal drugs (27, 72hours cultured) AMPH-B 5-FC FLCZ ITCZ MCZ MCFG 0.25 mg/ml 4 mg/ml 8 mg/ml 0.25 mg/ml 0.125 mg/ml 16 mg/ml (MIC) MIC Clinical and Laboratory Standards Institute (CLSI) M27-A 7) 9) MIC Table 2 MCFG MIC Fig. 5. Slide culture on 30th day (Lactophenol stain 400) (Fig. 4) Slide Culture 30 annellide annelloconidium 1 (Fig. 5) 3742 Czapek Dox agar (Candida spp.) E. dermatitidis 6) amphotericin B (AMPH) 5-fluorocytosine (5-FC), fluconazole (FLCZ), miconazole (MCZ), micafungin (MCFG) itraconazole (ITCZ) III. 10) MCFG150 mg/day 2 CT MCFG 300 mg/day 10 2004 3 4 E. dermatitidis 3 13 MCZ 400 mg/day 2 X CT MCZ 4 2004 4 14 2003 1 ICTZ 2004 4 14 5-FC 100 mg/kg/ day ITCZ 200 mg/day 2 E. dermatitidis 28 Vol. 18 No. 1 2008.
Exophiala dermatitidis 29 empiric therapy E. dermatitidis 10 3 cfu/ml 10 3 cfu/ml M J P2 (Fig. 1-b) E. dermatitidis 1 E. dermatitidis MEDLINE E. dermatitidis 3 11) 13) 27 E. dermatitidis E. dermatitidis 35 27 14) MCZ ITCZ 5-FC 2 MIC 1) Wang, Li., K. Yokoyama, M. Miyaji, et al. 2001. Identification, Classification, and Phylogeny of the Pathogenic Species Exophiala jeanselmei Vol. 18 No. 1 2008. 29
30 and Related Species by Mitochondrial Cytochrome b Gene Analysis. J. Clin. Microbiol. 39 4462 4467. 2) Nisimura, K., M. Miyaji. 1982. Studies on a saprophyte of Exophiala dermatitidis isolated from fumidifler. Mycopathologia 3(77): 173 181. 3) Revankar, S. G. 2007. Dematiaceous fungi. Mycoses 50(2): 91 101. 4) 2002. (1,3)-b-9-61: 28 37. 5) 2002. p. 110 115, 6) 1994. p. 189 190. 7) National Committee for Clinical Laboratory Standards (NCCLS). 1997. Reference method for broth dilution antifungal susceptibility testing of yeasts Approved Standard. NCCLS document M27-A. NCCLS, Wayne, Pa. 8) 2002. micafungin in vitro DEC 8 18. 9) Espinel-Ingro#, A., A. Fothergill, M. Ghannoum, et al. 2005. Quality Control and Reference Guidelines for CLSI Broth Microdilution Susceptibility Method (M38-A Document) for Amphotericin B, Itraconazole, Pasaconazole, and Voriconazole. J. Clin. Microbiol. 43: 5243 5246. 10) 2002. 61: 1 7. 11) Horre, R., K. P. Schaal, R. Sielmeier, et al. 2004. Isolation of fungi, especially Exophiala dermatitidis, inpatients su#ering from cystic fibrosis. Aprospective study. Respiration 71(4) 360 366. 12) Diemert, D., D. Kunimoto, C. Sand, et al. 2001. Sputum isolation of Wangiella dermatitidis in patients with cystic fibrosis. Scand. Infect. Dis. 33(10) 777 779. 13) Blaschke-Hellmessen, R., I. Lauterbach, K. D. Paul, et al. 1994. Detection of Exophiala dermatitidis (Kano) De Hoog 1977 in septicemia of a child with acute lymphatic leukemia and in patients with cystic fibrosis. Mycoses 37: 89 96. 14) 2002. 61: 19 27. A Case of Pulmonary Chromomycosis Caused by Exophiala dermatitidis Chiyoko Tanamachi, Kouji Hashimoto, Kazunori Nakata, Kimitaka Sagawa Department of Laboratory Medicine, Kurume University Hospital We report a rare case of pulmonary mycosis involving E. dermatitidis. The subject was a 53-year-old woman with a history of bronchiectasis whose primary complaints at the time of hospitalization were yellowish phlegm and anterior chest pain. Chest X-rays and chest CT images revealed a shadow in the lower right lung field, and pulmonary mycosis was suspected. Grocott staining of samples from the patient s bronchial lavage fluid showed many yeast-like fungi. When coughed up sputum and bronchial lavage fluid were cultured at 35, colonies formed which appeared to be black yeast. However, when cultured at 27 filamentous colonies formed, so we confirmed a diagnosis of the dimorphic black yeast Exophiala dermatitidis. After initial treatment with miconazole, combined treatment with itrazonazole and flucytosine proved e#ective. 30 Vol. 18 No. 1 2008.